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June 19, 2003


Emory Embarks on Research Study to Compare Early Surgical Intervention to Drug Therapy for Common Form of Epilepsy

ATLANTA Epilepsy - a neurological condition that produces brief disturbances in the normal electrical functions of the brain, often causing seizures - affects about one percent of the population, approximately 2 million Americans. The most common form of epilepsy is called temporal lobe epilepsy, and it causes seizures that often cannot be controlled with medication.

While some people with temporal lobe epilepsy have good control of their seizures using antiepileptic drugs (AED), others do not and often need surgical treatment to reduce their seizure activity. Usually surgical treatment is considered a last resort, to be used only if medications are not effective. Many studies have shown that surgery can stop disabling seizures in more than 80 percent of patients with temporal lobe epilepsy, but no research study has looked at surgery performed as an early therapy.

Therefore, researchers at Emory University are taking part in a multi-center trial to determine if patients treated early with brain surgery can become seizure free, and have improved quality of life, compared to similar patients who continue to receive antiepileptic medication only. The five-year study, funded by the National Institutes of Health, is called the Early Randomized Surgical Epilepsy Trial (ERSET).

"ERSET is the first randomized, controlled trial of epilepsy surgery which will compare the results of early surgical intervention for patients who have temporal lobe epilepsy, with the results of optimal treatment using antiepileptic medications," says Thomas R. Henry, MD, associate professor of neurology, Emory University School of Medicine, and lead investigator of the study at Emory. "Participants in this study must have had disabling seizures for less than two years after onset despite adequate treatment with two AEDs, one of which has been Dilantin, Tegretol or Carbatrol."

Temporal lobe epilepsy often becomes medically uncontrollable during adolescence and early adulthood. Repeated seizures during this time can cause adverse social and psychological events, which can become irreversible. Other symptoms include memory loss, difficulties in thinking, personality changes and poor abilities to learn.

"We hope this trial will help us to determine if early surgical treatment can permanently stop seizures, and can work better than medications alone, to avoid memory loss and other problems that increase year by year when seizures are not controlled," according to Dr. Henry, who is the director of the Emory Epilepsy Center.

In temporal lobe epilepsy, seizures are concentrated in the temporal lobes, the portions of the brain that extend from the temples to just past the ears. Certain parts of the temporal lobes control memory, language and visual tasks. Temporal lobe epilepsy causes a type of partial seizure, in which seizures begin in one part of the brain, but often then spread to other brain areas. About 60 percent of people with epilepsy have partial seizures.

Patients experiencing partial seizures may remain conscious or lose consciousness, experience unusual feelings or sensations, or display strange, repetitious behaviors. In contrast, generalized seizures, which result from abnormal neuronal activity in many parts of the brain, can cause loss of consciousness, falls, convulsions or massive muscle spasms. When the response to medication is very poor, partial seizures can evolve into generalized seizures.

Before patients can be recommended for epilepsy surgery, they must undergo a series of tests. The tests include neuropsychological assessments to find out what areas of the brain are needed for normal functions, electroencephalogram (EEG) or brain electrical activity recording to find out where in the brain electrical seizures are starting, and magnetic resonance imaging (MRI) to determine what parts of the brain, if any, have been injured by epilepsy or some other cause. These tests will help to insure maximum benefit for the patient and reduce the risks of adverse events.

Specially trained epilepsy neurosurgeons then use these test results as a guide for a type of brain surgery called anterior mesial temporal lobe resection. This procedure has been performed for about 20 years at Emory. The procedure involves removing a part of the temporal lobe, called the hippocampus, from the side of the brain where the seizures originate. The hippocampus is responsible for memory function. Epilepsy specialists say the part of the brain being surgically removed is already abnormal, so the impact of removal is likely to be much less dramatic than the removal of healthy tissue.

"In patients with temporal lobe epilepsy, repeated seizures cause scarring on the hippocampus, often resulting in memory deficits," says Robert E. Gross, MD, assistant professor of neurosurgery and neurosurgeon for the ERSET study at Emory. "However, following resection, patients typically do not experience further decline in memory. Their abilities to form new memories after surgery are not harmed."

By treating epilepsy patients with early surgery, researchers hope to learn if epilepsy-related problems, such as memory loss, difficulties in thinking and social and psychological events are less likely to develop. They also will look at the side effects of surgery compared to those that can develop from taking AEDs.

"Surgical treatment for epilepsy can completely stop seizures in many patients, but it remains one of the most underutilized treatment approaches," say Dr. Henry. "The main reason is that patients and many physicians are not well informed about the procedure." In fact, research shows that an estimated 100,000 to 200,000 patients with medically uncontrollable epilepsy in the U.S. are potential surgical candidates, but only 2,000 to 3,000 therapeutic surgical procedures for epilepsy are performed annually.

"This is the most gratifying procedure I perform," says Dr. Gross. "To remove the stigma of epilepsy and help give patients their normal return of function again is extremely rewarding."

Participants in the study will be randomly assigned to the surgery plus medication group or the medication only group. Participants must be over the age of 12 with disabling partial seizures, which have been medically uncontrollable for less than two years after onset. They must also have tried two antiepileptic drugs, one of which was Dilantin, Tegretol or Carbatrol, but did not receive good seizure control.

For more information or to find out if you might be a candidate for this research study, please call Emory Health Connection at (404) 778-7777. For patients who are not candidates for this research study, the Emory Health Connection can provide information on other medication or surgical treatments at the Emory Epilepsy Center.

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